Emergency Department Resuscitation of the Critically Ill, 2nd Edition

A Crash Course in Critical Care

Michael E. Winters, Michael C. Bond, Peter DeBlieux

• Publisher: American College of Emergency Physicians
• Year: 2017
• ISBN:
  9780998891248
• Edition: 1
• Topic: Medicina
• Subtopic: Medicina d'urgenza e terapia intensiva

A Crash Course in Critical Care!

Stabilize, treat, and save your sickest patients – in the ED or the field – with ACEP’s ultimate resuscitation guide. Packed with succinct evidence-based chapters written by the nation’s foremost authorities.

The second edition emphasizes:

• ECMO, sepsis, neuro, critical care, pulmonary hypertension, crashing obese patient, neonatal
• The addition of many new flow diagrams and diagnostic and treatment algorithms
• In-depth, up-to-date descriptions of the unique presentation, differential diagnosis, and management of specific critical illnesses

The ability to manage critically ill patients is perhaps the defining skill of emergency physicians. Whether performing rapid sequence intubation, initiating and adjusting mechanical ventilation, titrating vasoactive medications, administering intravenous fluids, or initiating extracorporeal membrane oxygenation, emergency clinicians must be at their best in these high-octane scenarios, during which lives can be saved—or lost.

Emergency Department Resuscitation of the Critically Ill focuses on caring for the sickest of the sick: the unstable patient with undifferentiated shock; the crashing ventilated patient; the decompensating patient with pulmonary hypertension or septic shock; the crashing obese patient; or the hypotensive patient with a left ventricular assist device. You’ll also find imperative information about managing pediatric and neonatal resuscitation, intracerebral hemorrhage, and the difficult emergency delivery.

What physiological possibilities must you consider immediately? What steps should you take now to save the patient’s life? The country’s foremost emergency medicine experts tell you everything you need to know to deliver rapid, efficient, and appropriate critical care. Quite simply, this book will help you save lives.

IN THIS CHAPTER

■ Assessing and stabilizing the patient in shock

■ Making a definitive diagnosis

■ The expanded RUSH examination

■ Vasoactive medications and push-dose pressors

Chad M. Meyers and Scott D. Weingart

The ability to adeptly manage patients who are in shock is among the defining skills of our specialty. In some cases, the cause of the shock state is immediately apparent. The hypotensive patient with a gunshot wound to the abdomen, for example, does not present a diagnostic dilemma. However, there are many other cases in which the diagnosis is neither quick nor simple. Emergency physicians frequently are forced to initiate resuscitation while simultaneously gathering the information needed to identify a patient’s underlying etiology.

Reduced to the simplest description, shock is inadequate tissue perfusion. In its early stages, patients might have a benign physical examination and normal vital signs. This shock state is sometimes referred to as cryptic shock and is revealed only by examining biomarkers such as lactate, or by using tissue perfusion monitors. For many emergency care clinicians, shock is almost synonymous with hypotension — a conflation that usually delays recognition of the shock state and results in a more challenging treatment course.

Low blood pressure should be taken into consideration when assessing an otherwise well-looking patient. Although it is tempting to discount borderline or transient hypotension, even a single episode of systolic blood pressure lower than 100 mm Hg has been associated with increased mortality in emergency department patients.¹ The lower the blood pressure observed, the higher the risk of death.¹ In cases of severe sepsis, the patient may experience transient self-limited dips in blood pressure.

Initial Assessment

In addition to the standard history and physical examination obtained on every sick patient in the emergency department, the following simple evaluations should be immediately performed on a patient with undifferentiated shock:

• Blood glucose measurement to screen for hypoglycemia
• Pregnancy test in female patients of childbearing age for suspected ectopic pregnancy
• ECG to identify arrhythmia and ischemia
• Assessment of feet and hands of abnorm vasodilation
• Examination of the neck veins as an indicator of paradoxically increased central venous pressure
• Rectal examination for melena/gastrointestinal blood for occult bleeding
• Chest radioraph to evaluate for pneumonia, pneumothorax or hemothorax, pulmonary edema

Initial Stabilization

After a patent airway and adequate oxygenation are red, it is crucial to establish access to the circulation. Short large-bore intravenous lines are the first option for venous access. If peripheral access is difficult, central venous catheterization, using a percutaneous introducer catheter or a dialysis catheter, provides a reliable means of fluid resuscitation. In addition, a variety of devices allow immediate cannulation of the intraosseous (IO) space and provide a reliable temporizing method in the unstable patient presenting without intravascular access. However, IO flow rates differ by anatomical site. While proximal tibial access quickly establishes a route for drug administration, the flow is not adequate for rapid volumes or blood products. When more aggressive resuscitation is required, proximal humeral and sternal IO cannulation combined with a pressurized bag or infusion pump can achieve flow rates comparable to those of an 18-gauge peripheral intravenous catheter.

Empiric fluid administration typically is the first consideration in the undifferentiated hypotensive patient. While overzealous volume resuscitation is associated with increased mortality, most unresuscitated hemodynamically unstable patients in the emergency department will benefit from a small bolus of crystalloid during the initial evaluation. The one exception is the patient with hemorrhagic shock, in whom crystalloid will further dilute hemoglobin, platelets, and clotting factors. Instead, blood products (eg, packed red blood cells, plasma, and platelets) should be used. After immediate priorities such as airway and respiratory compromise have been addressed, a rapid ultrasound survey (see below) can pro...